It's been more than 14 years since health information exchange (HIE) networks came to fruition. Over that time, the landscape in which HIEs reside has changed dramatically. A recent study conducted by MarketsandMarkets, a Dallas-based global market research and consulting company, explored the global HIE market over the forecast period of 2013 to 2018. The report, which estimated the market's value at $558 million in 2013, found that that figure is poised to reach $878 million by 2018. MarketsandMarkets viewed the rising demand for HIE and EHR technologies, the increasing number of federal government incentive programs, and the need to reduce health care costs as the major forces behind the growth.

Numbers aside, many industry leaders believe HIEs remain in the infancy stage, faced with ongoing challenges such as slow returns on investment and high implementation costs.

To gain an insider perspective on the successes and failures of HIEs, For The Record(FTR) spoke with Marc Probst, CIO and vice president of Intermountain Healthcare, and Dave Cassel, director of Carequality, an industry-driven collaborative focused on interoperability.

FTR: Dave, can you tell readers about Carequality and its objectives?

Cassel: Industry and government began working together on Carequality in the spring of 2014 through Healtheway. Participants wanted to tackle a big challenge in HIE, namely: How do we achieve in health care what the banking and telecom industries have done to link together ATM and cell phone networks? Right now, we have different types of exchange networks throughout the country building traction, but most still work independently of each other, and that's impeding all of our progress.

Carequality is an initiative aimed at creating a web of networks, tying them together into a whole that provides comprehensive interoperability throughout the United States. Carequality will allow the members of separate networks to connect to each other and ensure that health care information is appropriately accessible wherever it is needed, regardless of an individual provider's geographic location, EHR vendor, or HIE network affiliation.

FTR: The success rate of HIEs has been called into question recently. Can you talk about this skepticism in general?

Probst: It's hard to be successful when the process that you've been asked to accomplish is clunky. I've said before that HIE as an entity is a lot like the early Australian railroad system, where there was inconsistency between railroad gauges. These inconsistencies led to the creation of huge devices for moving products from one set of train cars to another, or in some cases lifting whole cars on top of other cars. Clearly such a process is ineffective and we've asked HIEs to do the same thing—move data from one system to another through very expensive and cumbersome interfaces. The task we've set them at is inviable financially and the data we've asked them to exchange—documents—are not as valuable as exchanging data.

Cassel: We've found that the success rate of HIEs varies dramatically based on a number of factors, including cultural, technical, location, timing, etc. Though each HIE is facing its own set of opportunities and challenges collectively, they can all benefit from a clearly defined set of rules and standards for interoperability between them.

From Carequality's perspective, we believe that interconnecting all types of exchange networks, including traditional HIEs, will really move the ball forward for everyone. We need a unifying set of implementation-level requirements that apply universally across all of these networks, to enable health information to flow seamlessly across what today are boundaries. That is precisely what Carequality is addressing through a multistakeholder collaborative process.

We see this connectivity as another way for an exchange network to provide value to its members. An exchange that meets local needs and provides innovative new programs, while also serving as an access point into standardized national connectivity, will be well positioned for success.

FTR: What are the ongoing IT challenges faced by HIEs? What must be done to tackle these challenges?

Probst: The lack of standards is the biggest issue. Security and consent processes also present massive challenges that both HIT and HIEs face. Patients own their data and therefore must consent before we share that information. As stewards of these data, we must minimize security risks that increase exponentially when data are replicated or stored in HIEs.

FTR: What are the interoperability issues facing HIEs?

Probst: History suggests that the government is best at enforcing core standards, such as rail gauges. Interoperability begins with a core set of standards that are either agreed upon by the industry or legislated. The railroad industry doesn't decide the gauge of tracks any longer. Once we have the core standards, then we can innovate and compete from a shared baseline. Continuing with the railroad example, innovation can improve the engine size and speed. It can find ways to be more efficient with transferring people and materials. Similar innovation can occur with data exchange that begins with core standards. Interoperability is about adoption.
We're doing a good job as an industry defining standards like open APIs [application programming interfaces], FHIR [Fast Healthcare Interoperability Resources], and SMART [Substitutable Medical Applications, reusable technologies], and then getting people talking about them. We need the government to enforce these so they actually happen.

FTR: Do HIEs receive enough support from the states and providers?

Probst: HIEs do receive support from the states and providers, but the disparity between the cost of HIEs and the value they return to providers is huge. The core problem is that HIEs need to be invaluable rather than unvaluable. By that I mean HIEs need to act less as entities and more as processes; that's where we'll find true interoperability.

FTR: Have HIEs been able to garner enough patient trust?

Probst: Patients will never trust an HIE and they shouldn't have to. They should trust that their providers and insurers have an HIE process—not necessarily an entity—that is secure, effective, and valuable.

FTR: Recently, three senators instructed the Government Accountability Office to investigate the HIEs that received almost $600 million in grant money from the Office of the National Coordinator for Health Information Technology but struggled to succeed. How is this investigation further impacting the issues facing HIEs?

Probst: This investigation isn't going to help unless there is fraud to discover. The reason HIEs aren't succeeding is that we set them up to do almost impossible things that no one really wanted. We never dealt with the core standards. William Stead, MD, associate vice chancellor for health affairs and chief strategy officer at Vanderbilt University Medical Center, was one of the first to speak about the need for standards. He phrased it as "data liquidity" and said this approach would make meaningful use successful. Unfortunately, we took too long to listen to what Bill was saying and our conversations focused on HIEs as entities rather than exchanging data as a process.

FTR: What do you think the future holds for HIEs?

Probst: We will get to standards, but we won't need HIEs for interchange. The idea of an HIE as an entity is outdated. We don't need to think up complex ways to transfer things between nonstandard railcars; we need to be able to do that without pauses, translations, and heavy lifting, which makes HIE an action. The future of HIE as an action is massive, but we will get there without an intermediary. That doesn't mean that the pioneering work of early HIE builders isn't valuable. It's because of their actions in promoting the conversation about interchange that we are finally getting back to talking about core standards.

Cassel: The space is evolving very quickly, and there likely isn't any single future for the whole category. Some exchanges are doing excellent work and serve as an example for others. Some have struggled but are regrouping to redefine their strategy and sustainability model going forward. It's hard to categorize HIEs as a whole due to these differences.

With that being said, a successful HIE cannot simply look inward. They must look outside of themselves and seek interoperability on a broader level. We feel that promoting connections among HIEs and other networks through Carequality is a critical step in brightening their prospects.